Resources

A randomized controlled trial found that the “Camden Core Model,” a short-term care management program for individuals with complex health and social needs and multiple recent hospital admissions, did...
Adults experiencing homelessness have high levels of health care needs, including those related to mental health and substance use disorders, and are more likely to visit the emergency department (ED)...
Care coordination programs for individuals with multiple chronic conditions and unmet social needs can be operationally complex, but little research has been done on staff effort within these programs...
Adventist Health Clear Lake, a health system in rural California, initiated a cross-sector collaboration between rural service providers and community agencies to more effectively address the needs of...
Incorporating patient self-reported data may allow health systems to more effectively identify specific groups of older adults with unique needs, thereby helping to inform the development of patient...
A telephone-based social needs screening, referral, and navigation program that focused on patients with predicted high utilization within the Kaiser Permanente Southern California health system...
Providing supportive housing for individuals experiencing homelessness who are identified as active substance users resulted in lower rates of SUD-related ED visits and hospitalizations compared to...
This resource describes a quasi-experimental study evaluating the effect of a transitional care program that involved rapid primary care follow-up for Medicaid and Medicare patients with complex needs...
Family caregivers are a critical part of the home- and community-based workforce for people with serious illness. This is particularly the case for veterans, who are often sicker than the general...
This study compared health services use and costs depending on whether the primary care provider was a physician, NP, or PA. NPs and PAs are taking a larger role in the primary care of medically...
This resource describes and analyzes the different professional compositions of care management programs. Based on a national survey of clinicians caring for complex populations, nearly 40 percent of...
This resource used national survey data from physician practices and ACOs, paired with qualitative interviews, to learn about home visiting programs. ACO practices were more likely to report using...